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Clin Res Cardiol (2014) 103:10251027
DOI 10.1007/s00392-014-0746-7
LETTER TO THE EDITORS
Transapical access for catheter ablation of left ventricular tachycardia in a patient with mechanical aortic and mitral valve prosthesis
Tilko Reents Susanne Stilz Ulf Herold
Isabel Deisenhofer
Received: 4 May 2014 / Accepted: 18 July 2014 / Published online: 25 July 2014 Springer-Verlag Berlin Heidelberg 2014
Sirs:
A 48-year-old man had received mechanical aortic and mitral valve replacement due to infective endocarditis in 1994. During a redo surgery, accidental occlusion of the left circumex coronary artery with a large postero-lateral myocardial infarction occurred and he received an ICD in 2008. An additional epicardial left ventricular lead was implanted in 2011 during a third sternotomy for closure of a paravalvular mitral leak.
Since November 2012, the patient had received multiple ICD shocks for recurrent VT (Fig. 1a) and electrical storm despite treatment with amiodarone 400 mg/day (QTc 430 ms) and high-dose betablockers (bisoprolol 10 mg/ day). A retrograde aortic and a transseptal route with transmitral access was contraindicated after mechanical aortic and mitral valve replacement. Epicardial access seemed impossible after three cardiac surgeries with presumed pericardial adhesions and epicardial LV lead placement. We therefore decided to access the left ventricle through a transapical approach.
Oral anticoagulation was stopped 2 days before the procedure and unfractionated heparin was used for peri-procedural bridging as soon as the INR was less than 2.5.
Heparin was stopped 2 h before the procedure and pre-procedural INR was 1.4.
The procedure was performed in the electrophysiologic (EP) catheter laboratory under general anesthesia. Access to the LV apex was achieved through a left anterolateral minithoracotomy along the fth intercostal space. Two pledgeted purse-string sutures were placed within the muscular tissue in the left ventricular apex region. After ventricular puncture and placement of a short guide wire, a short 8 F-sheath was placed in the left ventricle and a mapping and ablation catheter [4 mm Navistar surround ow (SF) irrigated tip, Biosense-Webster, Diamond Bar, CA, USA] was introduced (Fig. 1b). Unfractionated heparin was then administered once as a bolus (7,000 U, 80 U/kg). Hemostasis was guaranteed by tightening the purse sutures around the catheter shaft. Three-dimensional (3D) electroanatomic voltage mapping set to standard values was performed (CARTO 3, Biosense-Webster) to dene the low...